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ACC 2009 Advocacy Position Statement: Principles for Comparative Effectiveness Research
2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery
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J Am Coll Cardiol, 2008; 51:1369-1374, doi:10.1016/j.jacc.2007.11.071
© 2008 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: HYPERTROPHIC CARDIOMYOPATHY

Occurrence and Frequency of Arrhythmias in Hypertrophic Cardiomyopathy in Relation to Delayed Enhancement on Cardiovascular Magnetic Resonance

A. Selcuk Adabag, MD, MS*,*, Barry J. Maron, MD{dagger}, Evan Appelbaum, MD{ddagger},§, Caitlin J. Harrigan, BA§, Jacqueline L. Buros, BA§, C. Michael Gibson, MD, MS{ddagger},§, John R. Lesser, MD{dagger}, Constance A. Hanna, RN{dagger}, James E. Udelson, MD||, Warren J. Manning, MD{ddagger},§ and Martin S. Maron, MD||

* Division of Cardiology, Veterans Affairs Medical Center, Minneapolis, Minnesota
{dagger} Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
{ddagger} Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
§ PERFUSE Core Laboratory and Data Coordinating Center, Harvard Medical School, Boston, Massachusetts
|| Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts-New England Medical Center, Boston, Massachusetts.

Manuscript received August 2, 2007; revised manuscript received November 2, 2007, accepted November 26, 2007.

* Reprint requests and correspondence: Dr. A. Selcuk Adabag, Section of Cardiology (111 C), Veterans Affairs Medical Center, One Veterans Drive, Minneapolis, Minnesota 55417. (Email: adaba001{at}umn.edu).

Objectives: Our aim was to determine whether myocardial fibrosis, detected by cardiovascular magnetic resonance (CMR), represents an arrhythmogenic substrate in hypertrophic cardiomyopathy (HCM).

Background: Myocardial fibrosis is identified frequently in HCM; however, the clinical significance of this finding is uncertain.

Methods: We studied prevalence and frequency of tachyarrhythmias on 24-h ambulatory Holter electrocardiogram (ECG) with regard to delayed enhancement (DE) on contrast-enhanced CMR in 177 HCM patients (age 41 ± 16 yrs; 95% asymptomatic or mildly symptomatic).

Results: Premature ventricular contractions (PVCs), couplets, and nonsustained ventricular tachycardia (NSVT) were more common in patients with DE than those without DE (PVCs: 89% vs. 72%; couplets: 40% vs. 17%; NSVT: 28% vs. 4%; p < 0.0001 to 0.007). Patients with DE also had greater numbers of PVCs (202 ± 655 vs. 116 ± 435), couplets (1.9 ± 5 vs. 1.2 ± 10), and NSVT runs (0.4 ± 0.8 vs. 0.06 ± 0.4) than non-DE patients (all p < 0.0001); DE was an independent predictor of NSVT (relative risk 7.3, 95% confidence interval 2.6 to 20.4; p < 0.0001). However, extent (%) of DE was similar in patients with and without PVCs (8.2% vs. 9.1%; p = 0.93), couplets (8.5% vs. 8.4%; p = 0.99), or NSVT (8.3% vs. 8.5%; p = 0.35).

Conclusions: In this large HCM cohort with no or only mild symptoms, myocardial fibrosis detected by CMR was associated with greater likelihood and increased frequency of ventricular tachyarrhythmias (including NSVT) on ambulatory Holter ECG. Therefore, contrast-enhanced CMR identifies HCM patients with increased susceptibility to ventricular tachyarrhythmias.

Abbreviations and Acronyms
  CMR = cardiovascular magnetic resonance
  DE = delayed enhancement
  ECG = electrocardiogram
  HCM = hypertrophic cardiomyopathy
  ICD = implantable cardioverter-defibrillator
  LV = left ventricular/ventricle
  NSVT = nonsustained ventricular tachycardia
  PVC = premature ventricular contraction
  ROC = receiver-operating characteristic
  SVT = supraventricular tachycardia


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